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The Lean Methodology in Healthcare: Implementation, Improvement & Measuring Success

Author Taylor Spurgeon-Hess covers The Lean Methodology in Healthcare: Implementation, Improvement & Measuring Success on BackTable ENT

Taylor Spurgeon-Hess • Aug 10, 2023 • 32 hits

The Lean methodology offers a pathway to efficiency and continuous improvement in healthcare. Assembling a diverse team, including personnel from different areas like sterile processing and surgery, Lean drives an on-site problem-solving approach that enhances process coherence. The methodology's essence is embodied in Kaizen workshops, encouraging all involved parties to dissect and scrutinize each process part, fostering an environment of goal-driven innovation. Through this iterative approach, traditional components are constantly reevaluated, leading to the optimization of processes such as medical equipment management. The Lean approach goes beyond mere implementation, emphasizing measurable outcomes like staff proficiency and assembly time. Ultimately, Lean methodology holds the potential to advance healthcare operations, with the promise of a more efficient, patient-centered approach. Dr. Wolfgang Stehr discusses his experience with the Lean methodology in healthcare, as well as its application to bronchoscopy for pediatric airway foreign bodies.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Comprehensive groundwork is critical before the initiation of the Lean event, involving the review and interview of all stakeholders. Emphasis should be placed on understanding and improving the work at the actual workplace, rather than in isolated spaces.

• Hospital administration buy-in is necessary, with a focus on staff allocation for Lean activities. Ideally, about 3% of the workforce should be involved in Lean work.

• Kaizen involves the deconstruction and reconstruction of a process or an element to enhance efficiency.

• Encouraging inclusivity, openness, and equal participation across roles is vital in a Kaizen workshop. Innovative ideas are welcomed, tested, and adjusted, fostering an environment of continuous improvement.

• The PDSA (Plan-Do-Study-Act) cycle underlines the iterative nature of Lean, promoting continuous refinement of the process.

• Identifying and measuring practical metrics is crucial for evaluating process improvements. The application of Lean methodology to bronchoscopy involved systematically assessing the preparation time, correct assembly rate, and efficiency of bronchoscopy equipment.

• Standardized guides can significantly enhance the process, enabling even less experienced staff to assemble equipment correctly. Visual management forms a crucial part of Lean, emphasizing intuitive and clear signage and labeling.

• An effective education plan is key in Lean implementation, and it must identify who needs training, who will provide it, and tracking proficiency levels.

The Lean Methodology in Healthcare: Implementation, Improvement & Efficacy Measurement

Table of Contents

(1) Implementing Lean Methodology in Healthcare: Teamwork Dynamics

(2) Maximizing Process Improvement with Lean Methodology: An Overview of Kaizen Workshops

(3) Lean Methodology & Medical Equipment Management: Measuring Success

Implementing Lean Methodology in Healthcare: Teamwork Dynamics

The successful application of Lean methodology in healthcare is deeply rooted in a thorough understanding of the process steps, combined with comprehensive groundwork. An efficient team typically includes a Lean expert, an OR tech, an OR nurse, personnel from sterile processing, and surgeons. The essence of this methodology lies in the commitment to understand the actual workplace and the tasks at hand. This involves an examination of the place where the equipment is used and stored, and the stakeholders who interact with it. Lean insists on addressing the problem where the work is done, as opposed to an isolated office space, ensuring a more cohesive narrative of the work process. Furthermore, hospital administration and staff must be willing to commit their time and resources to Lean activities. In many cases, organizations begin with external consultants who eventually train internal personnel, enabling the process to be run internally, facilitating sustainability, data gathering, and impact assessment.

[Dr. Wolfgang Stehr]
I was maybe not very clear on how we put together the team and how we decide on the team. Usually there is a Lean expert, there's a person who understands the Lean methodology, who understands the different process steps. They already do a lot of groundwork before the Lean event actually starts. They review and interview all the different groups of people who may be involved in the process. There's the OR tech, there's the OR nurse, there's the person from central processing or sterile processing, and there are the surgeons. Not particularly this one, but in some Lean improvement workshops, we actually included the parents because we wanted them to be at the table to say this is what better would look like for us. You have the whole team and that team then comes together and we did sometimes two or three days of workshops in a row where on Monday we would say, "All right, this is our goal, this is what we're working with. Let's go out and look at the workplace, look at the place where the work is actually done and see what the reality is. How this equipment is being used, how this equipment is being stored, and who all touches this equipment in real life."

We're not trying to take a problem, take it out of the work area and move it into some back office and try to fix it in the back office. One of the key elements of Lean is you have to go look and see where the work is being done and that's where you're going to improve it, and that's where you're going to fix it, because otherwise, it's always people bringing their story or their part of the story into an office and you never get the whole story.

[Dr. Gopi Shah]
That makes sense. How important, in this situation, was it also to-- did you need to get hospital buy-in or any administrative level buy-in for something like this?

[Dr. Wolfgang Stehr]
Yes, because we take a few people offline and they are not doing their job. They're doing improvement work. Hospitals who engage in Lean methodology, they know that it takes the investment of taking folks offline to do this work in order to make improvements. In an ideal Lean world, about 3% of your workforce should be involved in Lean work. Sometimes that's a small portion of nurses that do a few hours so that over the year, maybe that's about 3% of their time. That's the investment the organization has to make. We were lucky we had an administration that embraced that process. They wanted this and they wanted us to be safer and better and of course save money.

[Dr. Gopi Shah]
No. That makes sense. In terms of having the Lean expert there to guide the process, who is that? Is that the chief quality officer of the hospital? Is that an external third-party consultant? How does that work?

[Dr. Wolfgang Stehr]
For most organizations, it starts with a consultant, and they come from the outside. Then they start to train people on the inside and ultimately the process can be run on the inside. I became trained to be a Lean expert and physician champion in the organization. After a few years of doing it, I was able to run the workshop, help prepare the workshop, but then it really also is helpful to have a Lean office because they then can help with the sustain, they can help gather the data, they can help see what impact did this actually make. There's multiple elements. Training people on the front-line to own the process is much more helpful and then feels much more natural because we've all experienced this. Some consultant comes, they don't know the organization that well, they don't know you that well, they don't know your processes that well. They start with asking a lot of questions. You already have the answers, so you don't really need them because you are the one who has the answers.

Listen to the Full Podcast

Airway Foreign Bodies in Children: Risk Reduction with Dr. Wolfgang Stehr on the BackTable ENT Podcast)
Ep 96 Airway Foreign Bodies in Children: Risk Reduction with Dr. Wolfgang Stehr
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Maximizing Process Improvement with Lean Methodology: An Overview of Kaizen Workshops

Kaizen, the heart of Lean methodology, involves dissecting a process or an element into manageable parts, thoroughly examining each, and reconstructing it in an optimized manner. This evaluation pivots on the perceived value of each process segment from different stakeholders' perspectives—parents, patients, insurance providers, or hospital staff. Importantly, Kaizen urges the questioning and reevaluation of even traditionally accepted components, such as waiting rooms. In the course of a Kaizen workshop, participants are introduced to Lean processes and are encouraged to voice their ideas equally, irrespective of their positions, to enrich the process improvement. Emphasizing an inclusive, open, and non-hierarchical atmosphere is crucial in fostering innovation, commitment, and the successful implementation of new processes. The iterative nature of the Lean process is embodied in the Plan-Do-Study-Act (PDSA) cycle, where proposed ideas are tested, evaluated, and refined continually for optimization.

[Dr. Wolfgang Stehr]
Kaizen means you take a process, you break it apart, and then you put it back together better. That can be a process, it can be a thing, but it's really about really breaking something down into small bite size pieces and then putting it back together. The question is always, is this a valuable element of this process? Would a parent want you to spend time on this? Would a parent or a patient want you to spend money on this? Would an insurance company want to pay for this? It's like you say, "Oh, we have a great new waiting room. The waiting room can hold 30 people. It's great." Actually, it's not great at all. Why do you need 30 people in your waiting room? That's a waste of their time. It's a waste of space. Maybe you could have an extra exam room instead of having your waiting room. Let's really challenge whether waiting rooms are a good thing. Sometimes they are. We all learned through the pandemic when the airlines broke down, all of a sudden you needed waiting space in the airports. It's difficult. Same with inventory management. One of the things about Lean is, let's make sure you limit your inventory to what you need, until a pandemic comes and we all run out of face masks.

It's something you really have to look at critical, but what happens in the kaizen workshop is you have a standardized process where you invite the right kind of people and teach them enough about the Lean process so that they can engage. Then you actually level set the expectation for the people where everybody has the same voice, which means if you have the chair of surgery and you have an OR nurse and you have sterile processing technician in the room, they all have the same voice because they know their area the best. If the person from sterile processing says, "I have an idea and this would work great for us because it would fit in our washers or would fit in our sterilizers," then let them run with it because people love their own ideas. If you let them run with their idea, then they'll be able to actually make sure that idea is successful. It's easy to take somebody else's idea and quickly think, "Well, that's never going to work. If that's what we're going with, I'm going to make sure that I'm right and it's never going to work." Make sure people can run with their own ideas enough to support it.

Then that's another element of the kaizen workshop where on day two or day three, you actually try out the new process. You actually pretend you go through a case and you try it out. Then you very quickly learn, this is better or this is not as good as I thought. Then you iterate on it and you do give it another try. You think about it again. Some people also talk about the PDCS circle,

[Dr. Gopi Shah]
The PDSA, Plan-Do-Study-Act?

[Dr. Wolfgang Stehr]
Correct, same thing. You have an idea, you try out the idea. If it's not as good as you want it to be, you go back around and you study it again and you look again and you change it again.

Lean Methodology & Medical Equipment Management: Measuring Success

To embrace continuous improvement, the most crucial step involves the abilty to measure efficacy. In the case of preparing bronchoscopy equipment, Dr. Stehr and his team chose three practical metrics: staff's ability to correctly assemble the set, the time required for assembly, and the number of drawers opened in the process, which was a proxy for efficiency. They conducted a baseline measurement revealing lengthy assembly times, a low success rate of correct assembly, and inefficient drawer usage. This measurement provided a clear starting point for improvement. In line with Lean methodology, the team strived for a visual management approach. The equipment's final configuration was designed to be visually intuitive, with clear, bold labels and a standardized guide with photos or diagrams to help even the least experienced staff members. Training was systematic, with an education plan listing who needed to be trained, the trainer, and their proficiency level post-training. This iterative process led to significant improvements: all tested nurses could assemble the set within two minutes without needing to open any drawers.

[Dr. Wolfgang Stehr]
Great. That's a really important question because we can only improve what we can measure. In this particular process, we looked very hard to see what are things that would actually show that we are doing better. We had three different measures. The first one was, can a nurse or a tech put this thing together so that it works? The second one was, how long does it take to put the equipment together? The third one was, how many drawers do you have to open in order to put this equipment together? The opening of the drawers in this big metal cart was a surrogate of how efficient is it put together.

When we started, I walked around and I asked 10 nurses, I said, "Hey, please put together a bronchoscopy set for a one year old kid." I had my stopwatch and I clicked and I watched them do it. It would take them 10 minutes. Out of 10 nurses, one was able to put this together, and they had to open an average of about 10 drawers, because you open the first one, it's not in there, you close it, you open the next one and it's still not in there, you open the first one again and finally you find it. Those were the three things. When we started, it took a long time. The ability of actually creating a functional setup was almost zero. Numerous drawers had to be opened.

[Dr. Gopi Shah]
Can the staff put it together, how long does it take, and how many drawers, how did y'all pick those as your outcomes to measure?

[Dr. Wolfgang Stehr]
It was hard to say, oh, how much money can we save when we do a better job because there's no dollar sign on your drawer. You sometimes need to really look and see, okay, what is a surrogate measure of time or a surrogate measure of success in order to look and see whether you're doing is better or not, because then on the back end, where we arrived, was I asked 10 nurses whether they could put it together and all 10 of them were able to put it together. It took 2 minutes and they had to open zero drawers. That was an improvement.

[Dr. Gopi Shah]
Then how often do you feel like people need training in putting the equipment together, because again, this isn't a high volume, this isn't doing tonsils, 10 tonsils in a day, 5 tonsils a day, and 10 tubes. They're frequent enough, but they're not once a week. How often do you have to train?

[Dr. Wolfgang Stehr]
Very important that you talk about education. The people who are engaged in the process, in the workshop, they know what to expect and they know, "Oh, we're doing this differently now." There are other people who have to touch it. There are other people who have to touch the equipment and so an important part of every kaizen workshop is a education plan. On the education plan, you have, what do people need to be educated on? Who are those people? You write them down by name. It's like, all of our 15 central sterile processing department technicians need to know, all of our nurses need to know, these are their names, and this is the person who is responsible to train them.

Then you go around and you check the box, you say, okay, this person was trained, they can do it to be somewhat proficient at it, and this person, because they work in the ENT room every day, they are an expert at it. You actually know, okay, these people need to be trained, these people were trained, and then most important thing, you write a document that is called a standard work document. Standard work can either live with the equipment or can live in sterile processing or can live in the operating room, where if you have a traveling nurse who knows nothing about your organization, they open the folder on standard work and in there they will find, this is how we use and put together bronchoscopy equipment, they can look at it, sometimes there's photos in it, sometimes there's drawings in it, so that even if they know nothing about your organization, they know nothing about pediatric bronchoscopy, they can still put it together.

[Dr. Gopi Shah]
In the moment, this folder is easy to use with a few minutes of understanding in the moment because I can't imagine that being on day one of orientation of the traveling tech or nurse for a procedure they may or may not have to experience.

[Dr. Wolfgang Stehr]
Exactly. That's another very important element of Lean management, which is making things visual. We call it visual management, so that the ENT cart doesn't have this tiny little three letters in the corner, ENT cart. It should be bold, it should be clear, it should have the right color. It's like, this is the ENT cart. Then you may have either a folder or some laminated sheets hanging on the side and you can pick it up and on there it's like, bronchoscopy. Then you look it up and all the information you need, how to put it together, is in there. Same with the equipment. We're going to talk about that in a minute, I guess. The equipment will be managed differently, so people can really visually quickly understand this is the ENT cart, this is how I do a bronchoscopy. They look through the drawers or the trays and then they see, "Oh, this is bronchoscopy."

Podcast Contributors

Dr. Wolfgang Stehr discusses Airway Foreign Bodies in Children: Risk Reduction on the BackTable 96 Podcast

Dr. Wolfgang Stehr

Dr. Wolfgang Stehr is a pediatric surgeon and medical director of surgery at Presbyterian Healthcare in Albuquerque, New Mexico.

Dr. Gopi Shah discusses Airway Foreign Bodies in Children: Risk Reduction on the BackTable 96 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, March 14). Ep. 96 – Airway Foreign Bodies in Children: Risk Reduction [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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